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Yu et al. Plast Aesthet Res 2022;9:37 https://dx.doi.org/10.20517/2347-9264.2021.124 Page 9 of 11

[38]
and no risk of injuring major vessels of the extremity . This technique requires a high level of technical
skill and should only be attempted by experienced microsurgeons. The size limitations of these perforator
flaps must also be kept in mind when considering supermicrosurgery as a reconstructive option.

Salvage procedures
When there are no recipient vessels or local flaps available, recipient vessels or donor tissue from the
contralateral extremity remain a viable option. Cross-leg flaps are not ideal as they have a high morbidity
rate and require prolonged immobilization as well as multiple operations [40,41] . If the alternative is
amputation and the patient is highly motivated to pursue this path, these flaps can be a final attempt at limb
salvage. The three types of cross-leg reconstruction are the pedicled cross-leg flap, the free cross-leg flap,
and the free cable bridge flap. For the pedicled cross-leg flap, the flap is raised on the contralateral extremity
and inset to the defect with the pedicle remaining attached to the contralateral leg. For the free cross-leg
flap, a free flap is an inset to the defect, and the flap pedicle is anastomosed to a recipient vessel on the
[40]
contralateral extremity. For the free cable bridge flap, Manrique et al. describe a multi-stage approach
where a radial forearm free flap is anastomosed to the contralateral extremity during the first operation.
During the second operation, another free flap is then attached to the radial forearm free flap and provides
coverage for the soft tissue defect. The radial forearm free flap in this situation acts as an interposition graft
to extend the reach for the second free flap. For all of the cross-leg flaps, the pedicle was divided after 3 to 4
weeks. An external fixator is placed to prevent avulsion of the flap.

CONCLUSION
There are multiple approaches and techniques that can be utilized in the reconstructive approach for
traumatic lower extremity wounds with limited recipient vessels. Each case must be approached
individually, and careful and considerate planning is critical for success. Lower extremity reconstruction can
be very challenging from both decision-making and technical perspective, but the rewards of salvaging the
limb are innumerable and should be attempted when possible.

DECLARATIONS
Authors' contributions
Performed literature review and primary manuscript writing: Yu JL, Tolley PD, Kneib C
Performed review and editing of the manuscript: Yu JL, Miller EA, Crowe CS

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
The study has been approved by our Institution Review Board, study number: STUDY00013819. There are
no specific ethical issues associated with the study.

Consent for publications
The copyright of the figures belongs to the authors.